Traumatic Spinal Cord Injury

39th CANP Annual Educational ConferenceMarch 18th, 2016 5:00pm-6:15pm

Carl Wherry, ACNP-bcAmanda Severson, ACNP-bc

Disclosures

• No conflicts of interest to disclose.

Introduction

• Incidence

– 40 cases per million population in the U.S.

– 12,500 new cases each year

– in 2014 estimated 276,000 people in U.S. living with spinal cord injury.

• Males account for 80% of SCI population

• Etiology: Vehicle crash > falls > acts of violence > sports.

Impact

• Hospitalization days average 11 days with 36 days average rehabilitation.

• Impact to health care of spinal cord injury (SCI)

Impact to life expectancy

Basic Anatomy

Tracts

Motor and Sensory

• Motor

• Sensory

Evaluation of Patient

Checklist for the first hour:

• Spine immobilization

• SBP >90

• Supplemental O2

• Early intubation for failure of ventilation

• Rule out other causes of hypotension

Mechanisms of Injury

Immobilization of suspected injuries

• Cervical spine immobilization until reliable

examination is possible (NEXUS or Canadian

C-Spine Rules)

Imaging

• Who to image:NEXUSCanadian C-spine rules (CCR)

Canadian C-Spine Rules

NEXUS Rules

The NEXUS rules are:

● No posterior midline cervical-spine

tenderness

● No evidence of intoxication

● A normal level of alertness

● No focal neurological deficit

● No painful distracting injuries.

Confirmed Injury

• Initial Management

• Airway

• Breathing

• Circulation

Airway

Intubation: Who?

•Complete injury @ C1-C4: early, elective intubation and mechanical ventilation.

•Parameters for urgent intubation – Complaint of "shortness of breath"– Vital Capacity < 10 mL/kg or less– "Belly breathing" or "quad breathing"

(abdomen goes out sharply with inspiration)

Airway

Intubation: How?•Awake, fiberoptic approach by experienced

provider •Urgent or emergent ->rapid sequence

intubation•Cervical in-line stabilization •TSI patients will already have loss of

vasomotor tone; medications that diminish the catecholamine surge may result in hypotension and bradycardia.

Breathing

• Indications for the intubation of the patient with traumatic cervical spine injury:– Complete SCI above C5 level– Respiratory distress– Hypoxemia despite attempts at oxygenation– Severe respiratory acidosis– Relative indications– Complaint of shortness of breath– Development of ‘‘quad breathing’’– Vital capacity (VC) of <10 ml/kg or decreasing VC– Consideration should be given– Need to ‘‘travel’’ remote from ED (MRI, transfer to another

facility)

Circulation

• Blood pressure support:

– Norepinephrine

– Phenylephrine

– Dopamine

– Epinephrine

– Dobutamine

Disability-Neurological Examination

• Motor and Sensory Exams

• ASIA scale

• Syndromes

– Anterior Cord Syndrome

– Central cord syndrome

– Brown-Sequard Syndrome

ASIA Scale

• (http://www.asiaspinalinjury.org)

A mixed picture

Anterior Cord Syndrome

• Loss of pain/temperature and motor but NOT light touch; due to contusion of anterior cord or occlusion of anterior spinal artery.

• Associated with burst fractures of spinal column with fragment retropulsion by the axial compression.

Central Cord Syndrome

● Loss of cervical motor function with relative

sparing of lower extremity strength.

● Typically due to hyperextension injury in

elderly patients with cervical stenosis.

● Often no fracture; rather, buckling of

ligamentum flavum contuses cord, causing

bleeding with the center of cord.

Brown-Sequard Syndrome

● Hemiplegia, loss of ipsilateral light touch,

AND loss of contralateral pain/temperature

sensation due to hemisection of the cord.

● Indicates a penetrating cord injury often from

missile or knife, or a lateral mass fracture of

the spine.

Autonomic Dysreflexia

Treatment

• Steroids?• Temperature

management• Stem cells• Venous thrombus

prevention

• Pediatric Consideration

NASCIS 2:

•Bracken MB, Shepard MJ, Hellenbrand KG, et al. Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study. J Neurosurg. 1985 Nov. 63(5):704-13.

NASCIS 3:

•Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylatefor 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA. 1997 May 28. 277(20):1597-604.

NASCIS trials reviewed

NASCIS graphs

NASCIS

CONCLUSION: A critical reevaluation of the clinical efficacy of steroid administration in acute SCI demonstrates that, despite a Class I trial and general widespread use, the evidence for 24-hour MP therapy in humans is negligible or weak at best . . . MP therapy should be regarded as potentially harmful and possibly lethal.

Hypothermia

•There are no randomized controlled trials

Stem Cells

Venous thrombus prevention

•Recommendations:

–Level II, Early administration of VTE prophylaxis (within 72 hours) is recommended.

–Level III, Vena cava filters are not recommended as a routine prophylactic measure, but are recommended for select patients who fail anticoagulation or who are not candidates for anticoagulation and/or mechanical devices.

Venous thrombus prevention

•Pharmacologic agents (Chest guidelines)

Case study #1

• 41 y.o. male. no significant PMHx, regular Marijuana user, who was brought in as critical code trauma after being pulled out of shallow water with bilateral arm and leg weakness.

• Patient dove into shallow water and was witnessed to be struggling per family who pulled him out. He was weak in arms and legs.

Case #1 physical assessment

Case #1 admit CT

Case #1 initial management

• CT Cervical Spine show unilateral locked left facet at C3-C4. Patient was placed in halo and 80lb traction for decompression.

• MRI obtained:

Case #1 MRI

Case #1 formal managment

• Admit: spinal cord injury, did external reduction with tongs, followed by halo. MRI and CT shows spinal injury. Ortho surgery handling spine.

• Day #1: appears depressed.• Day #2: Underwent C3- 4 decompression and fusion• Day #3: Hypotension in AM• Day #4: Robaxin for back pain, pan cultured, ongoing cooling• Day #5: emesis overnight, Dopamine weaned. Breathing well.• Day #6: pulmonary edema and infiltrates continue to be an issue. • Day #7: MAP therapy ends, and no significant change in the motor

exam. • Day #8: Transferred to 6N from ICU• Day #9: GI consulted: Methylnaltrexone 8mg SQ given

Case #1 post op imaging

Case #1 ICU transfer to floor:

• C3/4 ASIA B spinal cord injury, s/p C3/4 reduction of unilateral facet dislocation and posterior spinal fusion with instrumentation on by orthopedics. He has shown no signs of neurological recovery since his injury and remains quadriplegic with 0/5 in the UEs, 1/5 proximal LEs, 0/5 distal LEs.

• Sodium goal: 135 - 145

• prosthetics/ orthotics: Wear Aspen cervical collar at all times.Duration: at least 6 weeks and until instructed at follow-up appointment.

• Activity: as tolerated

Case #1 hospital discharge exam:

• Motor scores were: 0/5 strength in all extremities at this time. No change since admission. Internal rotation of hip 1/5 only.

• Motor Exam: Outward movement with pain and withdrawal bilateral lower extremity with painful stimuli. Right leg intermittent spasm.

• Sensory Exam:Light Touch and pinprick: No sensation below C6.

Case Study #2

Case #2 imaging:

References:

• ENLS reference

• NASCIS

• https://www.nscisc.uab.edu/reports.aspx

Contact

• Carl Wherry, ACNP-bc:cwherry@mednet.ucla.edu

• Amanda Severson, ACNP-bc:aseverson@mednet.ucla.edu